The use of recombinant tissue plasminogen activator (tPA) for acute ischemic stroke in the U.S. roughly doubled over a five-year period, researchers found.

Action Points

Explain that the use of recombinant tPA in the U.S. roughly doubled over a five-year period.

Note that the increase in treatment with tPA began before Diagnosis Related Group 559 was approved, which suggests that the financial incentive was not the only factor behind the trend.

The use of recombinant tissue plasminogen activator (tPA) for acute ischemic stroke in the U.S. roughly doubled over a five-year period, researchers found.

In 2009, an estimated 3.4% to 5.2% of patients with acute ischemic stroke received tPA, up from 1.8% to 2.1% in 2004, Opeolu Adeoye, MD, of the University of Cincinnati, and colleagues reported online in Stroke: Journal of the American Heart Association.

The reasons for the increase are unclear, but the researchers credited at least part of the greater usage to a financial incentive introduced in 2005.

In October of that year, the Centers for Medicare and Medicaid Services approved a new Diagnosis Related Group -- DRG 559 (acute ischemic stroke with use of a thrombolytic agent) -- which increased payment to hospitals for patients with acute stroke to $11,500, compared with $6,400 for DRG 14 (intracranial hemorrhage or stroke with infarct) and $4,900 for DRG 15 (nonspecific cerebrovascular accident or precerebral occlusion without infarct).

"This financial incentive, along with the establishment of formal certification of primary stroke centers by the Joint Commission, the various statewide initiatives to standardize acute stroke care, and the aggressive Get With The Guidelines campaign by the American Heart Association may have all contributed to the increased treatment rates," Adeoye and colleagues wrote.

They noted, however, that the increase in treatment rates began before DRG 559 was approved, which suggests that the financial incentive was not the only factor behind the trend.

To examine trends in thrombolytic use, the researchers used information from two databases -- the Medicare Provider and Analysis Review (MEDPAR) and Premier, a private nationwide hospital database.

Thrombolytic use was similar in the two databases from 2005 to 2009.

Using diagnostic codes, use increased from 1.1% in 2005 to 3.4% in 2009 within MEDPAR and from 1.4% to 3.7% within Premier (P<0.001 for both trends).

When the data from Premier were limited to patients older than 65 -- to match the patient population in MEDPAR -- thrombolytic use increased over the study period from 1.2% to 3.4% (P<0.001).

Consideration of pharmacy billing codes within Premier inflated the rates of tPA use compared with the use of diagnostic codes only -- use increased from 2.4% in 2005 to 4.5% in 2009 (P<0.001).

The researchers then included patients who were coded as having a transient ischemic attack (TIA) or a hemorrhagic stroke and also as receiving thrombolytic therapy. These patients were considered to have been miscoded and were believed to have actually suffered an ischemic stroke.

When those patients were included, the rate of thrombolytic therapy in 2009 rose to 5.2% within Premier -- the highest estimate -- and 3.8% within MEDPAR.

The authors acknowledged some limitations of their analysis, including the use of administrative datasets, the inclusion of patients coded as having TIAs and hemorrhagic strokes in some of the estimates, which may have overestimated tPA use, and the lack of information on the mode of delivery of tPA, the appropriateness of patient selection for treatment, and the potential impact of payer source and socioeconomic factors on the likelihood of thrombolytic treatment.

The study was supported by an Association of American Medical Colleges grant.

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.